Home Health & Hospice Week

Your peers' stats matter in determining the cutoff for review.

Question: What is the benchmark used to choose an agency for Targeted Probe & Educate review?

Answer: The Centers for Medicare & Medicaid Services and its contractors say a "high denial rate" will land a provider on - and keep it on - TPE review. But that's about as specific as Medicare gets on the topic.

"The error percentage that qualifies a provider/supplier as having a high denial rate varies based on the service/item under review," CMS says in a recently posted TPE question-and-answer set. "The Medicare Fee-For-Service improper payment rate for a specific service/item or other data may be used in this determination, and the percentage may vary by MAC. It is important to note that the determination of whether a provider/supplier moves on to additional rounds of review is based upon improvement from round to round, with education being provided during and after each round in order to help the provider/supplier throughout the process."

Note: See more Q&As at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Downloads/TPE-QAs.pdf.